Wiki Office visit and ear lavage

[wynonna]

If an office note mentions: Cerumen impaction and ear lavage, and also: otalgia, otitis media, otitis externa, dizziness, vertigo, hearing loss, conditions of tympanic membrane or auditory ossicles and these are being evaluated along with vitals being assessed and a general statement from MD about patient's appearance and gait, does this qualify as an office visit 99213, 99212 or ear lavage only?
In other words, may we bill a 99213 and 69209 for this visit based on above dx such as otalgia, otitis media, dizziness etc?
thanks

 

[HangarPilot]

I would say yes. It's not like the patient was previously seen and is coming in just for cerumen removal. The provider had to "work" for it ... they had to take a hx, do an exam, diagnose, etc. Sure, the end result is an ear lavage but the provider didn't know that walking into the room. Of the 50 possible causes for ear pain, they had to work it out.

If you take your car to the shop for a "check engine light" and the mechanic does the $120 diagnostic test and the computer tells him the gas cap is loose ... you get charged $120 to have someone tighten your gas cap! He had to "work" and use the diagnostic computer to arrive at that conclusion. It would be a different story if you came in stating "my gas cap is loose" ... he might tighten it out of goodwill or replace it for $20. Instead, he had to take the scenic route to get there.

If all you had was a dx of impacted cerumen, I would think twice about using that for a 99213 AND 69209. But since you have multiple dx, I'd say your on pretty sure ground (assuming of course the HPI and everything supports it). We take the same approach with foreign body removal, umbilical cautery, etc. If all we have is ONE dx, we really weigh billing for both. The presence of additional supported dx makes it easier in my opinion!

Don't forget, 69209 is unilateral, be sure to use the -50 if both ears were done.